Summary

In recent years, Robot-assisted Surgery, or Robotic Surgery is increasingly replacing traditional, open-incisional surgery, or even minimally-invasive equivalents such as Laparoscopy. With increased adoption in the coming years, Robotic surgery will overcome the cost barrier, and in a decade or two, most surgeries will be Robotic. In this article, we will discuss why and how Robotic Surgery is superior to Laparoscopic procedures.

Introduction to Types of Surgery

There are umpteen ailments, diseases, disorders, syndromes or conditions where medication and alternate therapies may not work. In such a case, surgery becomes the final, inevitable option. Surgical procedures are of broadly three types:

1. Open, incisional: Here, large incisions are made on the surface of the body, to open out the body at the desired location, and access the spot of surgical intervention. Disadvantages of this includes increased blood-loss, trauma or injury to tissues in the vicinity, scarring, long hospitalization, long recovery time and high cost. Having said that, there are some conditions or situations in which open surgery cannot be avoided.
2. Laparoscopy or ‘Key-hole surgery’: To overcome the disadvantages of open surgeries, minimally-invasive surgeries were pioneered in the 1980s and started becoming popular in the 1990s. Today, minimally invasive surgeries are done for a wide range of conditions. In this, smaller incisions are made on the body to introduce two or more thin scopes which have cameras, lights and surgical instruments fitted at their end. Disadvantages include limited flexibility or range of motion.
3. Robot-assisted surgery: In this, a large robot with four or more arms, and cameras, lights, and surgical instruments fitted at the end of the arms are used. The robot is controlled by a doctor, from an instrument panel that is placed next to the robot. Due to the superior range of motion and sophisticated capabilities of the robotic arms, the doctor can undertake complex interventions with ease.

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Also Read: Revolutionizing Cardiac Care – Robotic Surgery in Cardiology

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Laparoscopy in brief

An endoscope is a long, thin, flexible tube made of synthetic material. One end of the endoscope can be fitted with diagnostic equipment to investigate the condition. Endoscopes are extremely popular in diagnostic tests. As a natural evolution of this approach, laparoscopes were introduced to achieve surgical interventions. Here, endoscopes are fitted with camera, lens and light, just like in a normal endoscope. Further, they have stiff, stick like attachments that carry surgical instruments at the tip.

Once the patient is admitted into the OR, and sedated, the doctor makes small incisions around 5 centimetres long, on the skin, in the desired part of the body. While one incision is required to insert the scope with camera-light-lens fitment, one or more incisions are required to introduce scopes with the desired surgical attachments.

The camera-light-lens fitment relays images on to a computer screen kept in the OR. By looking at the same, the surgeon(s) can push the scopes around till they reach the exact spot. Thereafter, using the surgical attachments in the scopes, they can carry out the desired intervention.

Given the stiff, stick-like nature of the short arm-attachments, the surgeon’s range of motion is limited. Further, the cameras used are simple and compact, and they can only generate 2D images. It takes several years of practice, and skill to develop the ability to perform precise laparoscopic procedures. The surgeon must be physically involved in the procedure from start to finish. This leads to fatigue for him/her, not to mention shake and tremor in his/her hands. These are the primary disadvantages of laparoscopic surgeries.

However, Laparoscopy comes with the advantage of lesser cost compared to open-incisional surgery and robotic surgery, in most cases.

Robotic Surgery in brief

Given the drawbacks of Laparoscopy, they can be used only in some surgeries where complex manoeuvres are not required, and the intervention is fairly simple and straightforward. For example, they are used to diagnose several conditions that affect the abdomen or pelvis. They can also be used to carry out simple surgical procedures, such as removing a diseased or damaged organ or gland, or extracting a tissue sample for further examination.

However, there are several surgical procedures such as prostate surgery, Nissen fundoplication, lung resection, hysterectomy, treatment of gynaecological cancers such as uterine, ovarian and endometrial cancers, etc, that require complex or delicate manoeuvres, to achieve the desired intervention. The limited range of motion or flexibility available in a Laparoscopy becomes a drawback. So, previously, surgeons would fall back on open-incisional surgery as the other option. However, we know that open surgery is not for everybody. Its drawbacks become a limitation for the elderly and those with co-morbidities.

Robot-assisted surgery emerged as a better, and the third option, around the 2000s. As adoption of robot-assisted surgeries started picking up, the robots became more and more sophisticated with newer players entering the market. One of the most popular robots today is the ‘da Vinci Surgical system’ manufactured by Sunnyvale-headquartered Intuitive Surgical. We have already covered this in an earlier blog.

The da Vinci system has a console with instrument panel. A surgeon sits on a chair in front of this console, and operates the robot using joystick or toggle-switch like controls. The robot has four or more arms. One of the arms carries the camera-light-lens fitment, while the other arms carry long, thin, pen-like fitments with surgical instruments at the tip. Two-centimetre-wide incisions are made on the body to introduce the camera arm and the surgical arms inside the body at the desired spot. Up to this point, the procedure is similar to that of a laparoscopy.

However, the robotic arms have wrists which makes it easy to bend the arm-tips and move them horizontally and vertically.  The arms themselves can be moved over a large angle in all dimensions. Sophisticated controls in the arm tips can ensure a controlled, minute and precise intervention without any risk of tremor. Further, the cameras generate high-resolution 3D images. This gives a better depth perception to the surgeon, which minimizes trial-and-error moves that are common in Laparoscopy.

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Also Read: Robotic Surgery in Oncology – Breaking Barriers and Redefining Treatment

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Comparing the two

Parameter	Laparoscopy	Robot-assisted surgery
Sedation and anaesthesia	Mild sedatives and local anaesthesia	Local anaesthesia, with or without sedation
Precision and dexterity	Straight, stick-like arms with 4 degrees of freedom offer little flexibility	Endo-wristed arms and controls that mimic the human arm and fingers, while moving in 360 degrees freedom. This is beneficial while operating on hard to access areas like rectum, thorax, or female reproductive system.
Where the surgeon is positioned	Standing by the patient’s side. His/her direct involvement adds the risk of tremor and fatigue	Seated at a console next to the patient. Instruments have sophisticated controls to filter out tremor
Vision and magnification	Limited vision and magnification, with 2D and nowadays 3D imaging.	3D imaging with 10-12% magnification. This makes it easy to operate on thin blood-vessels, nerves and tiny lymph nodes.
Suturing	Challenging, especially when organs have to be rejoined after cancer treatments.	The fluid and flexible range or motion of the robotic arms makes suturing easy.
Stapling	Not available	Here, integrated energy devices and stapling mechanisms allows for a smooth and streamlined intervention.
Conversion to open surgery (the need to fall back on open surgery in case of failure)	Moderate to high, depending on the specific procedure	Low
Learning curve	Very steep. Surgeons need to do hundreds of laparoscopies to master the technique. This increases dependency on skilled or experienced surgeons.	Moderate. Given the sophisticated controls, and lack of direct involvement by the surgeon, moderately experienced surgeons can do an equally good job as highly experienced ones.
Cost	20-30% cheaper than Robotic Surgery	Costlier due to technical abilities and limited availability
Availability	Widespread. Including Tier-2 and 3 cities of India	Limited to large hospitals in Tier-1 cities of India
Duration of hospital stay	Lesser than open incisional surgery	Lesser than open incisional and laparoscopic surgeries
Blood-loss, trauma to nearby tissues, and scarring	Lesser than open incisional surgery	Lesser than open incisional and laparoscopic surgeries
Recovery	Faster than open incisional surgery	Faster than open incisional and laparoscopic surgeries
Chances of infection	Lesser than open incisional surgery	Lesser than open incisional and laparoscopic surgeries
Post-procedural complications	Lesser than open incisional surgery	Lesser than open incisional and laparoscopic surgeries

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Also Read: The Role of Robotics in Improving Outcomes of Kidney Transplants

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Outlook

Not everyone is suited for an open surgery which is why laparoscopy emerged. In the same way, not all procedures are suited for a laparoscopy, so Robotic Surgery which is superior, emerged. However, not everyone is suited for Robotic surgery too. While cost is a barrier for some patients and some procedures, the age and BMI of the patient, and nature of the condition becomes a limitation sometimes.

That is why, the decision to use the best possible option is made by a panel of surgeons and case-doctors after doing required diagnostic tests and discussing various aspects of the case. Large hospitals offer all these benefits, which minimizes decision-making dilemmas for the patient. The patient can just sit back and enjoy the benefits of medical technology, while looking forward to effective treatment.

 

Kauvery Hospital is globally known for its multidisciplinary services at all its Centers of Excellence, and for its comprehensive, Avant-Grade technology, especially in diagnostics and remedial care in heart diseases, transplantation, vascular and neurosciences medicine. Located in the heart of Trichy (Tennur, Royal Road and Alexandria Road (Cantonment), Chennai (Alwarpet & Vadapalani), Hosur, Salem, Tirunelveli and Bengaluru, the hospital also renders adult and pediatric trauma care.

Chennai Alwarpet – 044 4000 6000 •  Chennai Vadapalani – 044 4000 6000 • Trichy – Cantonment – 0431 4077777 • Trichy – Heartcity – 0431 4003500 • Trichy – Tennur – 0431 4022555 • Hosur – 04344 272727 • Salem – 0427 2677777 • Tirunelveli – 0462 4006000 • Bengaluru – 080 6801 6801

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